because i have been getting a little flack from a certain miss anjali regarding my non-activity on this blog, here is something i wrote in March. I remember Langston Hughes said something like when you are busy living life, it is sometimes hard to sit and write. Or maybe that is my own lackluster interpretation to justify my lack of writing. -sri

from march... on the wards.

people walk around with so much. heavy-ness. carry it and tuck it away.

it is one in the morning. My last patient for the night. A tough black woman. 60 yrs old. sweet but tough. short gray hair and a quick smile but a smile like she's been working so long without a break. her lungs are kinda shot. she has smoked for so long and is wheezing now. wheezing so much you can hear it when you enter the crowded, noisy ER room. she had a Lakers hat on and a Lakers blanket and I started chatting with her about how the Lakers suck right now and you could tell she had been watching the Lakers for a long long time.

It is always great to talk about Cooper and Byron Scott and Magic and showtime. That itself makes the day. So after examining her, i tell her she will have to be admitted upstairs.

She got all freaked out and said "I don't do elevators I am closterphobic and I can't ride an elevator" Her sister is with her and says "She don't get on no elevators-She scared of them closed space. Her sister leaves and I say we can sedate her but she will have to take the elevator.

All of a sudden she starts to shake like a leaf. Her right hand shaking and she starts to cry. Not a sad cry, a scared spontaneous cry.

I squat down to look her in the face since her Laker hat is blocking my view as I stand over her. I tell her I can walk her slow up the stairs if she wants but "what's up- Why are you so scared"?

She says she doesn's tell anybody this but when she was seven, her uncle locked her in a closet and raped her. and she hasn't taken the elevators since. not once. she is 60 now. She said her aunt died a few years back and she went to the funeral and she brought a gun to kill that man. That uncle who had raped her. and sadder than seeing the aunt dead in a casket was finding out that that uncle had been dead for two years. She said she wanted revenge -- for that man who broke her to the point that she couldn't have kids. she can't pee without keeping the bathroom door open. She was never married.

There are certain things that are a Fuck You in the moment but don't make you feel any better. I told her that her life, her leading her life healthy and standing still without fear, without a running away is the biggest Fuck You to that man. That dead man who had raped her fifty some odd years ago. I felt like telling her that without forgiveness for that man her own heart would be affected. but it felt contrived and what do I know of rape and a trespass of something so sacred that you can never feel safe in your skin.

so i was getting paged and paged and a man was dying upstairs and i had to go... but i told her I would be back to figure this out with her and make it upstairs with her.

the man dying upstairs is another story- i shocked him with paddles. it took till 4:30 am to stabalize him. my DNR/DNI patient died at 2:30 in the morning and the family was bedside and I didn't make it there until 5 in the morning. to sign the papers and talk to the family. and the daughters in spanish said doc, you abandoned us. you took care of our father for so many days and his body has been cold for two hours and where were you? and my spanish is okay with a capital OKAY and i mustered something not very convincing.

i kept getting paged by the ER and I called back and they said you have a patient here who will not be taken upstairs until she talks to the doctor. it is now 6 in the morning and i have not slept and I run downstairs and my patient says doc what happened to you. You abandoned me. and I tell her what went down. and ask her if i can walk her slow up the stairs.

she says No. She will take the elevator. And I ask if she is sure. and she says she is.

And I go to round on her in the morning and she is on the third floor and she tells me like a kid who has just hit the winning shot in march madness. she made it up the elevators.

sri

needles, flower essence, placebo and other health tools

clinic has gotten busy lately. we are now seeing on average 15 people per half day with jumps up to 25 at times. sicker people. the word has spread that we can do D&Cs for early pregnancy loss at least 1-2 women a week show up with miscarriage and we've had a rash of women with cholecystitis who have wound up hospitalized and surgerized with very complex medical/surgical cases. one woman required an eight hour surgery. interestingly enough, i haven't been able to send a single patient to the public hospital (University) because they are so full, there are no beds. and when given a choice, these very poor patients would rather get respectful care, receive a much higher bill and hope for some mercy from the non-profit hospital (Presbyterian). dignity and respect definitely rank higher than inexpensive, hostile care.

so last night, in the middle of a busy clinic, an older gentleman came in complaining of severe pain that he could no longer tolerate. he had a recent diagnosis of Rheumatoid Arthritis and Heart Failure, and he was sad and upset with the deterioration of his body. he was well insured and under the care of a primary care doctor, an arthritis specialist and a cardiologist, all of whom were very responsive to his needs. he was already on percocet for pain, a fairly sizable dose, but it wasn't taking care of his pain.

i was confused at first, i wasn't sure what i could do for this man. he made it clear that he wanted to try alternative medicine for his pain, try anything actually, that worked, and he had heard that we did integrated medicine at the clinic. i must admit, i felt a moments hesitation and insecurity, what could alternative medicine do that steroids and opiates couldn't for pain?

we dug a little deeper - he was clearly interested in acupuncture as a potential treatment. both the nurse practitioner and myself were trained in ear acupuncture for helping drug addicts detox more comfortably. neither of us claim to practice acupunture. that requires years and years of education and study. but i was on the spot last night. he was in pain, asking for help, strong drugs weren't cutting it and compassion moved me to "PRACTICE" medicine. I informed him that my skills were limited but that i could insert some needles in his ears and we would see what happens. this was after giving him a referral to a real acupunturist, but it was late in the day and there was no way to know when he would get the appointment in the future.

fortunately, i had also actually studied reflexology which uses the same map of the body on the ear so i was familiar with other points aside from the detox points. i put five needles in each ear, on the major joints and some "master" points that assist the body overall in healing. i left the man in the waiting room on a comfortable couch and started seeing other patients. about 45 minutes later i checked in with him and he had a HUGE grin on his face; he felt better. he was thankful to me and left eager to get a full acupuncture treatment.

don't ask me to explain how it works, i can't give you a mechanistic description. but clinical evidence is clinical evidence and this man benefited. at a cost of $30 for the consultation and the needles.

in the world of primary care, whether we are MDs, DOs, DOMs, NDs, NPs, PAs, Chiropracters, Massage Therapists, Traditional Medicine practitioners, Herbalists, Energy healers, etc, we all have the same task - diagnose the problem with some degree of accuracy, help people find their health when they are out of balance, and identify people who are so out of balance that they need hospitalization or specialist care to address their dis-ease. this requires humility and courage. the humility to know your limits and the courage to truly "practice" medicine, to try things with attention to minimizing cost, harm, grief (yours and the patients) and suffering.

there is NO ROOM to do any of this in the managed care world. the incentives, the environment, the "standard of care" all define the parameters of what's okay and what's not okay to do. there is no place for intuition, for reasonable, cautious experiement, for learning completely new and potentially amazing tools. every change in the system is a battle, a power game, a decades-long struggle by "alternative medicine" practitioners to earn the right to have insurance companies pay for their services.

boring. lame. gag me with a spoon.

i'm appreciating working in an environment where we can play, where we can try things out that seem utterly ridiculous on the surface, that have no scientific explanation (yet) but put smiles on our patients faces when "standard of practice" medicine can't do the job.

primary care calls for some creativity but there should be a method to the madness.

here's my theory of everything -

1. diagnose the problem. do this with as little invasive technology as you can, stay humble and re-evaluation your diagnosis if there is poor therapeutic response to treatment.

2. figure out the cheapest, simplest, least side-effect, most human dignifying solution, even if the success rate is not guaranteed to be 100%. placebo is a great example. in study after study of high tech drugs, placebo always comes in a close second on cure. CURE. not feeling better or some soft endpoint. CURE. it averages around 30-40% CURE. sit with that for a while if you are a practitioner. it's amazing. imagine the personal and social cost savings if everyone were to try placebo first and the 60% of treatment failures were then to move on to more expensive modalities. with this as a known scientific fact, you can't go too far wrong trying almost anything that is non-toxic, inexpensive and potentially useful. it gets weird (and criminal even) when you start pushing a particular "remedy" that cures everything, that costs alot and that you make tons of money off of. this is a form of abuse of placebo that charlatans can use to play off people's suffering.

3. the first line therapy may be antibiotics, flower therapy, flax seeds and aloe juice, ear acupuncture, a short course of benzodiazepines, prozac, hospitalization, surgery. it all depends on the diagnosis, severity of illness and your breadth of knowledge.

4. if first line therapy fails, move on up the ladder of cost, invasiveness and dependency.

5. remember that every step of the way it is the patient who decides (this is primary care, not a major trauma in th ER where the rules are different) and you who offer suggestions, insights, ideas and recommendations.

in our clinic we are learning to use inexpensive, interesting home remedies, nutritional remedies and energetic remedies (like flower essence and homeopathy). with the patients consent, these become first line BEFORE major antidepressants or anti-anxiety drugs, before laxative treatments or antacids and proton-pump inhibitors. those who fail the less expensive options can be quickly switched over to cholesterol lowering drugs and the purple pill (nexium) and xanax and prozac and all the mish mash of pharmacological glory our generation of scientists has produced.

as with any scientific endeavor, we are tracking patients who are beginning on these therapies and doing case studies to document success and failure. anecdotally, first response is very positive. within two years i'd like to have a whole series of independent interviews analyzed that can help to understand the usefullness of this approach amongst our patients.

andru

Report-back from HMO "row"

Last week, I mentioned here that folks were gathering in Woodland Hills, CA (san fernando valley) to go on a "walking tour" of the headquarters of several HMOs -- putting together an innovative education and creative direct action event.

Here's a link to a podcast by the California Nurses Association around the event, and Deborah Burger (president of the california nurses association) wrote a report-back from the event, at the Huffington Post:

Everything you need to know about can be found in just one block of America, a quiet business-park block in a San Fernando Valley town named Woodland Hills. Here we find such the headquarters of such titans of the healthcare world as Blue Cross/Blue Shield, Wellpoint, Health Net, and Meridian Healthcare Management.

In just this handful of companies, we find the three values that mark today's system of big-business healthcare: denial of care, cash register politics, and huge profits amidst a growing crisis.

Our tour guide Sue Cannon, RN, starts at Blue Cross, to talk about the corporate need to save money by denying care--hardly the way a health CARE system is supposed to work. We're at Blue Cross because they've just been sued by numerous patients who've for"retroactive denial of coverage." Here's how that works: you get sick and Blue Cross approves a certain medical procedure. Then they go over your original application to see if they can find any inconsistencies; if so, they boot you out of the system, and leave you with the bills they just approved...

Our final stop is WellPoint, to discuss the disparity between huge healthcare industry profits and the growing crisis of the uninsured. WellPoint used to be a for-profit division of non-profit Blue Cross. Subsequently, it bought Blue Cross of California, turning the whole organization for-profit. Why? In the words of one stock analyst, to "liberate them from their social responsibilities." This liberation led to $2.5 billion in profits in 2005, and $157 million in direct compensation to their top five executives over the past three years. Yet HMOs have led the fight against a universal healthcare system based on a single standard of care for all, despite the fact that some 50 million Americans and over 6 million Californians have no health insurance.

Denial of care, cash register politics, and record profits from a health care crisis. That's the health care system we enjoy in America today. Thousands of people die unnecessarily each year because of this, and every year we fall further behind countries like Canada and England that haven't handed their health care off to big corporations like these in Woodland Hills.

And, I just received an update from CNA organizer Joseph Newlin on an upcoming CNA day of action:

July 11 is going to be a major day of action around the country to protest an anticipated ruling from the National Labor Relations Board that would re-classify thousands of nurses as supervisors and make them ineligible for union membership.

Reclassify nurses as supervisors because they make clinical patient care assignments to other staff? (rendering them incapable of having union representation) What? More information here. Can we think of other creative ways to exacerbate the critical shortage of nurses in our country?

I'm sure the national Committee of Interns and Residents (CIR) union, of which our hospital's resident physicians are well organized around and which is part of the Service Employees International Union (SEIU), will be working with the CNA on this action. I'll keep ya'll updated. If we don't support our nurses, who are the backbone of our healthcare system, the system will will go to hell in a bigass diaper and no amount of policywonking or healthcare reform will matter.

Always and never

A pediatric cardiologist I worked with today reminded me of this piece of wisdom (from psychologist wendell berry) as we discussed a kid's physical exam findings and possible diagnoses:

"Always and never are two words you should always remember never to use."

Seems to make so much sense in the field of medicine, where the strongest truisms are always refuted and the mysteries of the mind and body are never wholly understood. Oops.

May Garriage

Boo: Senator Bill Frist is pathetic for pushing the gay marriage amendment to the floor of the Senate but blocking numerous other important bills from reaching the floor. The power he has as Senate Majority Leader is obscene. I think we need an amendment to broaden who makes decisions on what bills are allowed to be discussed (in committee or on the floor of the house or senate).

Ooh: Lou Dobbs is incensed. Dobbs, a not exactly center of the road kinda guy, gives congress the smackdown. He delves into our education system, poverty, lack of health care access, and our Congress' unrepresentative priorities in his CNN piece:

Dobbs: Gay marriage amendment sheer nonsense

...The president and the Senate's Republican leadership are now claiming that an amendment to our Constitution is necessary to save the American family. No matter how you feel about the issue, and many of us feel deeply, a constitutional amendment to ban gay marriage is utter and complete nonsense. It's an insult to the intelligence of every voter, Republican or Democrat, liberal or conservative....

The president and the Senate are focusing on one of the few reasons that has not been proven to cause divorce. They instead should look to financial hardships, and the lack of communication about family finances. The median family income is stagnating while gasoline costs and higher interest rates are eating up the family budget...

Both political parties love to excite and enliven their so-called "bases" by focusing on wedge issues like gay marriage, abortion, gun control, school prayer and flag burning. Both the Republicans and Democrats raise these issues to distract and divert public attention from the pressing issues that affect our way of life and our nation's future.

Are these wedge issues really how Congress should be spending its time, especially given how little time politicians spend in Washington, D.C., these days? I'd rather see our 535 elected representatives and this president use their time to combat poverty, fix our crumbling schools, secure our broken borders and ports and hold employers accountable for hiring illegal aliens. And like millions of Americans, I am desperate for a resolution to our wars in Iraq and Afghanistan.

How can we tolerate elected officials who press wedge issues when 37 million people in the United States live in poverty, one in every eight Americans? Almost 18 percent of children under the age of 18 live in poverty -- 13 million children.

Nearly 46 million people live without health insurance, about 16 percent of the population, a number that has risen by 6 million since 2000. More than one in 10 children are uninsured, and one-quarter of people with incomes below $25,000 also lack any health insurance.

College costs are skyrocketing. There's been a 40 percent jump (inflation-adjusted) in tuition and fees at public four-year colleges and universities over the past five years, according to the College Board. The costs for brand-name prescription drugs have also increased twice as fast as the rate of inflation. In fact, over the past six years, the average rise in the price of brand-name drugs is 40 percent, according to the AARP.

But while these increases in the price of the basics make it harder for hard-working men and women to make ends meet, the president and Congress would rather drive wedge issues than work toward real solutions.

I wonder if the president's political advisers know just how ill-advised and smarmy this wedge issue looks to the millions of us who want solutions to the critical, urgent problems facing this nation. Worse, I wonder if they even care.

Taking a walk down "HMO Row"...

I'm posting the following because it's a great example of a creatively planned event (not because I expect totheteeth readers to trek over to the san fernando valley, ca -- but if you can, go go go!). It's really exciting to see a health care reform event utilizing education, direct action, and creative filming:

On Wednesday, June 7, nurses, patients and healthcare activists will host a Walking Tour of 'HMO Row' in Woodland Hills. Join us for a short, guided tour of several insurance company office buildings, with descriptions of the harm these corporations are doing to patients as we advocate for Medicare for All-a national bill (HR 676) authored by Rep. John Conyers (MI), and a California state bill (SB 840) authored by Sen. Sheila Kuehl.

Please come and support this San Fernando Valley event for Universal Health Care.

Wednesday, June 7
11:00 AM
Blue Cross Headquarters
Corner of Owensmouth and Oxnard
Woodland Hills, California
Parking available at the mall by AMC Theaters.

Come shortly before 11:00 AM, since the event will begin promptly.
Don Schroeder will be filming this event and Doris Nelson will be speaking for SB 840 representing HCA.

Hope to see you,

John Glass
Outreach Coordinator
Health Care for All-San Fernando Valley Chapter
(818)766-6381
If you can come, please let me know at jglasshouse@earthlink.net

Or call the California nurses association -- 818.637.7115 or 510.273.2202

Big Ideas

This is big. I received an email from MoveOn.org, about the results of the house parties they had all over the country (over 100,000 attendees) and subsequent voting to choose their top three Big Ideas to work on for the next phase of their (our) actions. Parts of the email are below, it's pretty impressive how front-and-center health care reform is among the moveon members (obviously a little more left-leaning than your average joe, and possibly more middle-upper class -- not even sure of this actually). Someone told me back in the day, movements really push forward in this country when (1) self-interest is at stake and (2) the issues start seriously affecting the middle-class, not only the low-income folk. So, ya wanna join in?

Dear MoveOn member,

The results are in. We're proud to announce the MoveOn member choice for our new, positive agenda:

• Health care for all
• Energy independence through clean, renewable sources
  
• Democracy restored

These three goals were nominated, debated, and overwhelmingly selected by more than 100,000 people in local house parties and then online. Most groups would say this is a far too risky way to make such a big decision. But it's this grassroots consensus that makes this agenda different—and powerful...

Our strength lies where it always has: the voice, energy, and creativity of 3 million MoveOn members. If we're going to make health care a right, power America with clean energy, and restore our democracy, we're going to need as many likeminded folks on board as we can get. So today, we're turning to you to help build the team.

When the polls closed Wednesday night at 11:59, "Health care for all" and "Energy Independence: clean, renewable sources" were the clear winners for the first and second plank, with 82.8% of voters choosing one or both. We're proud to put these bold, inspiring goals front and center in our work to come...

It's exciting to know how united we are—a full 96.8% of voters chose at least one of these top issues.

We've set our eyes on a pretty big prize here, and there's a lot of hard work to do. But our history is full of stories of millions of people uniting behind a vision and fighting together 'til they've achieved the unthinkable. And heck, most of them didn't even have email.

Let's make it happen.

–Ben, Matt, Adam Green, Marika, Justin, Jennifer, Carrie, Rosalyn, Eli, Adam, Tom, Noah, Wes, Joan, Tanya, Natalie, Roy and Nita, the whole MoveOn.org Political Action team

Friday, June 2nd, 2006

P.S. The online vote was between the 10 most popular goals that MoveOn members generated and sent in from over 600 house parties last week. Here are all of the "MoveOn top 10" and the final vote count for each:

Health care for all	65091
Sustainable energy independence	61030
Restored constitutional rights	35675
Guaranteed accurate elections	35133
Global leadership through diplomacy	28912
High quality education for all	27874
Solutions to global warming	26306
A guaranteed living wage	25527
Publicly funded elections	21096
A balanced federal budget	20945

P.P.S During the voting, members were asked to add their own words about why these goals are so important. Here's what just a few had to say:

Health Care for all:

We need a system that is equitable and affordable for all...Health care should not be treated like a commodity. We have 46 million uninsured and many million more who are underinsured and don't have adequate health care. It is estimated that 18,000 people die each year because they don't have adequate health care that works out to 50 people every day. We cannot continue to tolerate a fragmented health care system which worries more about profits and stock holders than it does the well-being of Americans. It is time for a systemic change which will bring down the cost of health care.
–Rebecca E. from Ithaca, NY.

I think that people with health care sometimes think that this is just a problem for the uninsured, but that is absolutely not true. Even if you have health care and develop a serious illness (cancer, MS, etc.) while covered by your employer, you better be sure you love your current job. Because if you decide you want to change direction in your life, you will become all too familiar with the words "preexisting condition". You will find you most likely cannot get coverage from a new provider. This system traps us all, insured and uninsured. We need comprehensive, affordable health care so that all of us can have the freedom to live our lives the way we want to, doing what we love, not being trapped by the health care system.
– Rebecca p. from Moose, Wyoming